|Practitioner:||Dr Peter Fisher|
Failure to consider history
Inadequate consultation and assessment
Inadequate medical notes
Inadequate care and/or follow-up
|Additional Orders:||Director of Proceedings denied application for adjournment
Adjournment Order appealed by the Director of Proceedings - appeal dismissed by the District Court (Director of Proceedings v MPDT and Dr Fisher (District Court, Wellington, CIV-2003-085-1608, Dalmer DCJ, 12 November 2003))
The Director of Proceedings charged that Dr Fisher was guilty of disgraceful conduct in a professional respect or alternatively professional misconduct. The particulars of the charge alleged:
- Failed to adequately assess the patientís:
- Psychiatric and/or forensic and/or social and/or medical history; and/or
- Phenomenology of mental state; and/or
- Alcohol and drug history; and/or
- Precipitants for admission; and/or
- Prior response to and adverse effects of, his previous and current treatment; and/or
- Risk; and/or
- Failed to adequately document [his] assessment and/or diagnostic formulation of the patient; and/or
In-patient period 10 February 21 March 2001
- Failed to undertake and/or record a thorough and systematic review of the patientís mental status; and/or
- Failed to undertake and/or record an adequate assessment of the patientís risk; and/or
- Failed to follow-up and/or review the patientís:
- Alcohol and drug assessment; and/or
- Needs Assessment; and/or
- Failed to adequately develop and/or review the patientís:
- Medication regime; and/or
- Treatment and management plan; and/or
- Failed to adequately document:
- Clinical interactions with the patient; and/or
- Assessments of the patientís care and management; and/or
- Management and treatment plans; and/or
- On or about 22 March 2001 failed to undertake and/or record a thorough and systematic review of the patientís mental state prior to the commencement of his trial leave on 22 March 2001; and/or
- On or about 22 March 2001 failed to undertake and/or record a comprehensive risk assessment for the patient prior to the commencement of his trial leave on 22 March 2001; and/or
- On or before 22 March 2001 failed to make adequate arrangements for a review of the patientís mental state during his week of trial leave; and/or
- On or before 22 March 2001 failed to ensure a crisis plan was developed in partnership with the patient and/or recorded; and/or
- On or about 30 March 2001 failed to undertake and/or record a thorough and systematic review of the patientís mental state; and/or
- On or about 30 March 2001 failed to undertake and/or record a comprehensive risk assessment for the patient; and/or
- On or about 30 March 2001 failed to adequately review the patientís management and/or treatment plan; and/or
- On or before 30 March 2001, failed to make adequate arrangements for the patientís post-discharge care by:
- ensuring the adequate involvement of the patientís key worker (Community Mental Health Team) in discharge planning; and/or
- ensuring the adequate and timely monitoring of the patientís mental status and/or risk once he was discharged; and/or
- ensuring the adequate involvement of the patientís family in discharge planning; and/or
- Between 22 March 2001 and 30 March 2001 failed to ensure a crisis plan was developed in partnership with the patient and/or recorded.
Dr Fisher came to New Zealand in 1992 and gained full registration as a medical practitioner in New Zealand in March 1993. Initially Dr Fisher was employed as a psychiatric registrar by the Southland DHB. His status changed to Medical Officer Special Scale (MOSS) during the course of 1994. Dr Fisher held positions as a psychiatric MOSS at Southland Hospital and Seaview Hospital in Hokitika from 1994 to early 1999. In October 2000 Dr Fisher was again employed as a MOSS in the psychiatric department of Southland Hospital. Dr Fisher was still employed as a MOSS at Southland Hospital when the events giving rise to the hearing occurred.
The term MOSS is used to describe a doctor who has general registration under the Medical Practitioners Act 1995 (ďthe ActĒ) and who is employed in the public health system below the level of a vocationally registered practitioner (specialist). A MOSS may have considerable experience but is nevertheless not eligible to be registered as a specialist.
At the time of the patientís admission to Southland Hospital on 10 February 2001 he was a 19 year old who had been diagnosed as have schizophrenia and who also had a history of alcohol and drug abuse.
The patient first came into contact with mental health services in July 1998. The patient was observed to have features consistent with psychotic illness. He had a history of alcohol and cannabis use. The patientís parents were concerned about his aggressiveness and his excessive use of alcohol. Treatment was commenced by medication supervised by the patientís parents.
Throughout 1999 the patient continued to receive medication and appeared to be a consistent user of alcohol. In the middle of 2000 the patientís mental state fluctuated. In mid 2000 the patientís parents expressed concern about the safety of the patient, his brother and sister. The patient was admitted as a voluntary in-patient to Ward 12 of Southland Hospital on 23 June 2000.
In mid August 2000 the patientís parents noted a period of deterioration in the patientís mental state. In September 2000 a comprehensive management plan was re-visited. In November 2000 it was thought the patient was displaying symptoms of a relapse.
In mid January 2001 the patientís mother expressed concerns about the patientís anger and his aggression towards her. The patient was observed to be restless, suffering disturbed sleep and conversing in a bizarre manner. This pattern of behaviour continued through to early February 2001.
On the night prior to 10 February 2001 the patient went out drinking with friends. The following morning (Saturday 10 February) the patientís mother went to the patientís bedroom to see if he was home. The patient verbally abused his mother and threatened to attack her. The patient alleged his mother and brother kept interfering with him at night and that he would get them and kill them. The patient also reiterated allegations he had previously made that his parents had stolen $76 million from him. His parents realised the patient needed urgent psychiatric help. The patient was able to be pacified and agreed to accompany his father to the Southland Hospital. During the drive the patient reiterated his claims about his mother and brother and that his parents had stolen from him. He also commented that the Matrix was watching.
When the patient and his father arrived at Southland Hospital they were seen by Dr Fisher and nurse I. The patientís father stayed with his son during the admission interview. Dr Fisher made brief notes. Following the admission interview the patient was admitted to Ward 12 of Southland Hospital as a voluntary patient. Dr Fisher amended the patientís medication on admission.
On 11 February the patientís father wrote a detailed letter to Southland Hospital. That letter was received in Ward 12 on 14 February 2001.
The patient remained a voluntary in-patient in Ward 12 from 10 February to 30 March. On 22 March he went on a weekís trial leave.
Despite efforts by nursing staff and Dr Fisher, the patient did not wish to discuss the issues which illustrated his paranoia and delusions. In particular the patient was very guarded and circumspect when efforts were made to explore his belief that his brother and mother had sexually interfered with him and that his parents had stolen $76 million from him. It is apparent from the nursing notes that the patient continued to display paranoia about his parents and siblings. The patient also expressed hatred towards his mother and sister. On ten separate days in February and March notes which indicate the patientís psychosis were made by nursing staff. The incidents which constituted evidence of the patientís psychosis fluctuated during the time he was a patient in Ward 12, but were never resolved.
Soon after the patientís admission Dr Fisher began focussing upon managing the patientís leave from Ward 12. The first reference to the patient having leave can be found in a note made by Dr Fisher on 14 February.
A referral for a needs assessment was initiated on 12 February 2001. In fact the assessment was not able to be commenced until 8 March. The assessment was never completed.
The nursing notes record the patient left Ward 12 on two occasions in circumstances which constituted an abuse of his leave privileges. On 16 March nursing staff recorded the intention to find accommodation in Invercargill for the patient, and a flat was found which the patient was able to move into on 22 March.
On 17 March the patient spoke to his father about returning his car from Queenstown. The patientís father did not want the patient to access his car and wished to find out where the patientís flat was. The patient refused to allow the hospital staff to disclose to his father the location of the patientís flat. The patient was still angry with his father for not agreeing to the patient having his car. Dr Fisher then spoke with the patientís father. The patientís father told the Tribunal that when Dr Fisher telephoned him, he said that he did not see the patient coming back to Queenstown as an option because he had no place to stay and it was in too close proximity to his family. The patientís father ultimately agreed to bring the patientís car to Invercargill.
On 22 March the patient was placed on a weekís trial leave. A social worker was assigned to visit the patientís flat each working day. The social worker visited the patient on 23 March and noted the patient had a supply of beer and whisky. The patient had continued to drink beer and whisky on 26 March and a similar entry is recorded in the nursing notes for 28 March.
A discharge planning meeting was held on 30 March. The meeting was held 1Ĺ hours earlier than planned because the patient showed up at Ward 12 earlier than scheduled. The re-scheduling of the discharge meeting meant the key worker in the Community Mental Health Team who had been assigned to the patient was unable to attend the discharge meeting.
On the evening of 30 March the patient returned to Queenstown. In the early hours of the morning of 31 March, the patientís father heard on his police radio that there was a fire at his house. He rushed to the scene where he found his wife dead.
The patient was subsequently arrested and charged with the murder of his mother. In August 2001 a jury found the patient not guilty of murder by reason of insanity. The patient was committed as a special patient.
The Tribunal recorded in a generic manner that it was satisfied all the allegations that Dr Fisher failed to record, or adequately record his clinical observations, findings, assessments and plans were established.
The Tribunal considered it was necessary to stress the importance of clear and informative medical notes. It considered it exceedingly important that a medical practitioner such as Dr Fisher charged with the responsibility of caring for patients like the patient fully and accurately record their clinical observations, management, treatment and crisis plan. The Tribunal was satisfied Dr Fisher failed to adequately discharge his responsibility to perform these basic tasks.
When particular 1.1 was considered, the Tribunal found that although there were a number of significant deficiencies in Dr Fisherís assessment of the patient on 10 February, the deficiencies did not justify a disciplinary finding. The Tribunal had reached this conclusion because the deficiencies in the admission assessment could be excused as the admission was an emergency and occurred on a weekend. In addition it would be normal for a full and thorough assessment to be completed within a few days of admission to remedy deficiencies that occurred at the time of admission.
The Tribunal was satisfied particular 2.1 was established. The Tribunal believed Dr Fisher conducted only cursory reviews of the patientís mental state while he was a patient in Ward 12. There was nothing in the clinical notes to suggest that an assessment of the patientís delusions was properly explored. There was also nothing to suggest that specific incidents (such as some acts of aggression on 24 February and 12 March) were properly explored by Dr Fisher.
The Tribunal was satisfied Dr Fisher believed he was not out of his depth and fully able to conduct a mental state assessment of the patient and failed to appreciate the mental state assessments he did conduct were inadequate.
The Tribunal was satisfied particular 2.2 was established. The Tribunal was in no doubt Dr Fisher failed in his duty to ascertain the extent and nature of the patientís delusions, and what these delusions meant in terms of his ongoing level of dangerousness. The Tribunal considered a MOSS practising in a psychiatric unit in New Zealand in 2001 should readily have identified and explored these matters as part of their obligation to undertake an adequate assessment of the patientís risk.
The Tribunal found in favour of Dr Fisher in relation to both limbs of particular 2.3 of the charge. The Tribunal accepted Dr Fisher had sound grounds for believing there were no residential and counselling programmes available to the patient because he displayed no willingness to desist from abusing alcohol and drugs. The Tribunal concluded that whilst it was unfortunate no one appears to have ďfollowed upĒ the obtaining of a needs assessment report on the patient, Dr Fisher cannot be held accountable for this shortcoming.
The Tribunal found both limbs of particular 2.4 of the charge
established. Dr Fisher failed in his responsibilities to adequately
develop and/or review the patientís medication regime. He also failed to
discharge his responsibilities to adequately develop and review the
patientís treatment and management.
The Tribunal was concerned Dr Fisher resolved that the patient should leave Ward 12 for a weekís trial leave in the following circumstances:
The Tribunal considered the decision to ďtreat and manageĒ the patient by allowing him to go flatting was poorly thought through by Dr Fisher. Leave arrangements should have been planned on a graduated basis and in circumstances where the patientís ability to care for himself had been properly evaluated.
When considering particular 3.1 the Tribunal was in no doubt Dr Fisher failed to undertake an adequate, let alone a thorough and systematic review of the patientís mental state prior to his going on trial leave. Dr Fisherís attempts to assess the patientís mental state at any time between 10 February and 30 March 2001 were only cursory and failed to properly evaluate and explore the patientís psychosis.
The Tribunal was satisfied particular 3.2 was established It considered the risk assessment which Dr Fisher did perform was cursory and inadequate.
The Tribunal determined Dr Fisher did make adequate arrangements to review the patientís mental state during the week of trial leave and therefore particular 3.3 was not established. The patient was to be visited each working day by a social worker. The Tribunal considered it was reasonable to expect the social worker to note and report any significant change in the patientís demeanour, presentation and general well being. The patient was seen by Dr Fisher on 27 March which afforded Dr Fisher with an opportunity to re-evaluate the patientís mental state. In addition, the patient visited the Wardís workshop during the week of his trial leave. This provided a further opportunity for others to observe the patient and report if there were any notable changes in his presentation. The Tribunal considered although these arrangements were not ideal they did nevertheless indicate thought was given to trying to monitor the patient while he was on trial leave.
The Tribunal was satisfied particular 3.4 was established. Dr Fisher failed to prepare a proper crisis plan before his patient left the ward on a weekís trial leave.
The Tribunal was satisfied particular 4.1 was established. A thorough and systematic review of the patientís mental state should have been carried out on or before 30 March 2001. At discharge there was no proper evaluation of the patientís ongoing psychosis which should have occurred. The Tribunal believed if Dr Fisher felt unable to properly explore the patientís delusions and the risks these posed for his family, then he should have enlisted the assistance of a specialist. The Tribunal considered it was a serious breach of professional responsibilities for Dr Fisher to agree to the patient being discharged when his delusions had not been properly assessed and evaluated.
The Tribunal was satisfied particular 4.2 was established. It considered Dr Fisher failed to place due weight on the fact that the patient was still psychotic at the time of discharge and had consumed significant quantities of alcohol while on trial leave. The patient had a history of decompensation associated with substance abuse. He was in a flat by himself without social or family support. He by now had his car which offered him the opportunity to quickly return to Queenstown. These factors could not be outweighed by the patientís improved sociability.
The Tribunal was satisfied particular 4.3 was established. A number of deficiencies in the discharge treatment and management plan for the patient were identified. Those deficiencies included:
The Tribunal was satisfied particular 4.4(a) was established. It considered Dr Fisher was partially at fault over the unfortunate failure to ensure the key worker from the Community Mental Health Team was present at the meeting. However, in this case, the Tribunal considered it would be unreasonable to hold Dr Fisher liable in a disciplinary forum for communication errors which occurred.
The Tribunal was satisfied particular 4.4(b) was established. Dr Fisher did not put in place appropriate arrangements to ensure that the patientís mental state and/or risk were monitored in a timely fashion once he was discharged. It considered the key community worker needed to be actively and fully involved in planning the patientís discharge. Dr Fisher envisaged that the Community Mental Health Team would become involved in planning the patientís discharge at a further discharge meeting which he scheduled for 6 April 2001. In the Tribunalís view it was not appropriate for the Community Mental Health Team to become involved in planning the patientís discharge a week after he had in fact been discharged. It considered the arrangements put in place to monitor the patientís mental status and risk once he was discharged were unsatisfactory. They were in essence the same as for the period of the patientís trial leave.
The Tribunal was satisfied particular 4.4(c) was established. Dr Fisher did not adequately involve the patientís father in planning the patientís discharge. It was clear that the patientís father was not invited to attend the discharge planning meeting. Of even greater concern to the Tribunal was that Dr Fisher did not tell the patientís father about key incidents that had occurred while the patient was in Ward 12 and on trial leave. The patientís father did not learn until many months after his sonís discharge that the patient had abused alcohol and continued to be psychotic. The Tribunal accepted that if the patientís father had known about those matters he would have opposed the patientís discharge.
The Tribunal was satisfied particular 4.5 was established. The Tribunal considered Dr Fisherís ďinformal crisis planĒ did not meet the minimum requirements expected of a discharge crisis plan.
Although the Tribunal believed Dr Fisherís errors and omissions were serious it decided that the cumulative effect of his conduct fell short of disgraceful conduct in a professional respect. Accordingly, it found Dr Fisher was guilty of professional misconduct.
The Tribunal considered Dr Fisherís shortcomings were serious. The Tribunal was very concerned Dr Fisher failed to appreciate his own short comings and inadequacies in this case. He continued to labour under the impression that his performance was satisfactory (other than in relation to record keeping). The Tribunal found this lack of insight by Dr Fisher was at times distressing to observe.
The Tribunal ordered: